As used in this subpart, unless the context indicates otherwise—
means any of the procedures that deal with the review of adverse organization determinations on the health care services the enrollee believes he or she is entitled to receive, including delay in providing, arranging for, or approving the health care services (such that a delay would adversely affect the health of the enrollee), or on any amounts the enrollee must pay for a service, as defined under § 422.566(b)
. These procedures include reconsiderations by the MA organization, and if necessary, an independent review entity, hearings before ALJs, review by the Medicare Appeals Council (MAC), and judicial review.
Enrollee means an MA eligible individual who has elected an MA plan offered by an MA organization.
Grievance means any complaint or dispute, other than one that constitutes an organization determination, expressing dissatisfaction with any aspect of an MA organization's or provider's operations, activities, or behavior, regardless of whether remedial action is requested.
Physician has the meaning given the term in section 1861(r) of the Act.
means an individual appointed by an enrollee or other party, or authorized under State or other applicable law, to act on behalf of an enrollee or other party involved in the grievance or appeal. Unless otherwise stated in this subpart, the representative will have all the rights and responsibilities of an enrollee or party in filing a grievance, and in obtaining an organization determination or in dealing with any of the levels of the appeals process, subject to the applicable rules described in part 405 of this chapter
[63 FR 35067
, June 26, 1998, as amended at 65 FR 40328
, June 29, 2000; 68 FR 16667
, Apr. 4, 2003; 70 FR 4738
, Jan. 28, 2005; 75 FR 19812
, Apr. 15, 2010]